Background : This study verify the role of duplex Doppler venous examination (DDVE) in assessment of possible alternative diagnoses when DVT of lower extremity is excluded in patient with painful swollen lower limb which is a common clinical presentation with DVT ; However ,not frequently a range of pathologies are instead diagnosed. Objective : The aim of this work is to study the alternative diagnoses identified during duplex Doppler venous examinations (DDVE) of the lower extremities and their significance in patient management.The painful swollen lower limb is a common clinical presentation, with deep vein thrombosis (DVT) often the top differential. Methods : This study was carried out at Radio diagnosis Department, Zagazig University Hospitals, The present study was carried on 42 patient with a painful swollen lower limb or lower limb edema. Diagnostic work up was done including ultrasound and duplex Doppler US. Results : A total of 392 lower extremity venous Doppler examinations were reviewed and evaluated in 362 patients. Deep venous thrombosis was observed in 114 patients .Among the remaining 254 patients with unconfirmed DVT, 96 positive alternative diagnoses in 96 patients [representing 37.8% of patients negative for DVT (96/254) and 26.5% of all studied patients (96/362)] were identified. Conclusion: The clinical diagnosis of DVT is challenging. Unilateral complaints such as painful swelling of the leg, with or without accompanying redness, are common symptoms of many conditions besides DVT .Duplex ultrasonography of the lower extremity has become the first-line diagnostic test to detect DVT, with a sensitivity of 91% to 96% and a specificity of 98% to 100and also to assess other alternative diagnosis.